Malignant Strictures Research Articles

Laparoscopic-assisted ERCP following RYGB: a 12-year assessment of outcomes and learning curve at a high-volume pancreatobiliary center.

Treatment of pancreaticobiliary pathology following Roux-en-Y gastric bypass (RYGB) poses significant technical challenges. Laparoscopic-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP) can overcome those anatomical hurdles, allowing access to the papilla. Our aims were to analyze our 12-year institutional outcomes and determine the learning curve for LA-ERCP. A retrospective review of cases between 2007 and 2019 at a high-volume pancreatobiliary unit was performed. Logistic regression was used to identify predictors of specific outcomes. To identify the learning curve, CUSUM analyses and innovative methods for standardizing the surgeon's timelines were performed. 131 patients underwent LA-ERCP (median age 60, 81% females) by 17 surgeons and 10 gastroenterologists. Cannulation of the papilla was achieved in all cases. Indications were choledocholithiasis (78%), Sphincter of Oddi dysfunction/Papillary stenosis (18%), management of bile leak (2%) and stenting/biopsy of malignant strictures (2%). Median total, surgical and ERCP times were 180, 128 and 48min, respectively, and 47% underwent concomitant cholecystectomy. Surgical site infection developed in 9.2% and post-ERCP pancreatitis in 3.8%. Logistic regression revealed multiple abdominal operations and magnitude of BMI decrease (between RYGB and LA-ERCP) to be predictive of conversion to open approach. CUSUM analysis of operative time demonstrated a learning curve at case 27 for the surgical team and case 9 for the gastroenterology team. On binary cut analysis, 3-5 cases per surgeon were needed to optimize operative metrics. LA-ERCP is associated with high success rates and low adverse events. We identify outcome benchmarks and a learning curve for new adopters of this increasingly performed procedure.

Utility of palliative EUS-guided biliary drainage using lumen-apposing metal stents: a prospective multicenter feasibility study (with video)

Biliary drainage with ERCP is successful in only 80% to 90% of cases of extrahepatic cholangiocarcinoma and pancreatic cancer. We present the results of a multicenter prospective study assessing the safety, feasibility, and quality of life of patients after EUS-guided biliary drainage (EUS-BD) with lumen-apposing metal stents after failed ERCP. All consecutive adults with a dilated common bile duct (CBD)≥14mm secondary to inoperable malignant distal CBD stricture and failed ERCP biliary drainage were screened and recruited from 3 tertiary UK centers. Technical success of EUS-BD using lumen-apposing metal stents was the primary endpoint. Improvement in serum bilirubin level, 30-day mortality, procedure-related adverse events, and quality of life were secondary endpoints. Improvement in quality of life was measured using a validated questionnaire (EORTC QLQ-BIL21). Twenty patients were included in the analysis. EUS-BD was technically successful in all patients and the clinical success rate was 95% (19 of 20) at day 7 (>50% reduction in bilirubin level) and 92.3% (12 of 13) at day 30 (bilirubin<50 μmol/L). There were significant improvements in overall quality of life score (49 vs 42, P= .03) at day 30. All-cause 30-day mortality was 20% and the moderate adverse event rate was 10% (1 cholangitis and 1 stent migration). EUS-BD has acceptable technical success and safety as a second-line palliative treatment for inoperable malignant distal CBD strictures. Randomized controlled studies comparing EUS-BD with percutaneous transhepatic biliary drainage are needed to determine their effectiveness in clinical practice. (ISCRTN registration number: ISRCTN13196704.).

Tracheal stent placement provides opportunity for subsequent anti-cancer therapy for cancer patients with malignant respiratory complications.

Critically ill patients with severe acute dyspnea due to malignant tracheal stenosis or tracheoesophageal fistula often need advanced respiratory support. Tracheal stenting is an important palliative treatment of such patients. This study retrospectively analyzes the efficacy and outcomes of airway stenting in patients with tracheal stenosis or tracheoesophageal fistula. Patients underwent stenting from 2005 to 2018 in a single center were reviewed. Ninety-seven patients with malignant tracheal stenosis and/or tracheoesophageal fistula who underwent stenting were analyzed, all these patients had poor respiratory status. The median survival time of patients after stent placement was 119 days. Forty-five patients were treated with anti-tumor therapy after placing the stent. Discharged intensive care unit (ICU) within 3 days and postoperative antitumor treatment were independent predictors for the survival time after tracheal stenting (P<0.05). Tracheal stent implantation played an important role for additional anti-cancer treatment.

Endoscopic ultrasound-guided biliary drainage of malignant stenosis, not treatable with endoscopic retrograde cholangiopancreatography: a single-center, prospective observational study.

Background and study aims The therapeutic role of endoscopic ultrasound (EUS) evolved in recent decade,s opening a new chapter in the field of endoscopic biliary drainage (BD). EUS-BD has emerged as a new mini-invasive technique for neoplastic jaundice not amenable to endoscopic retrograde cholangiopancreatography (ERCP). The primary study aims were to assess the clinical efficacy of EUS-BD using an electrocautery-enhanced lumen apposing metal stent (ECE-LAMS) in patients with malignant biliary obstruction with failed\\unfeasible ERCP and the adverse event (AE) rate. The secondary aims were to evaluate the technical success and incidence of jaundice recurrence. Patients and methods Data from All patients referred to our tertiary-care Institute with obstructive jaundice due to unresectable malignant distal biliary stricture and unfeasible\\failed ERCP, were prospectively recorded from January 2015 to February 2018. The procedures were performed by a single-step ECE-LAMS (AXIOS-EC, Boston Scientific) placement, from the upper gut lumen to the biliary tree, for definitive biliary decompression. Results Twenty-one patients were consecutively enrolled. Mean pre-procedure common bile duct diameter was 16 mm and the bilirubin level was 13.9 mg/dL (range 3.8–29.5). LAMS was positioned from the duodenal bulb (n = 19) to gastric antrum (n = 2). We registered a 100 % of technical and clinical success. No AEs occurred. We observed a single case of delayed AE consisting of a buried LAMS, which was successfully resolved endoscopically. Conclusions Despite the limits of being non-comparative, our study shows outcomes in a homogeneous population in terms of indications and technique. EUS-BD with dedicated ECE-LAMS is associated with extremely good clinical efficacy and safety and can be considered as an alternative in cases of failed/unfeasible ERCP.

Contributions of Airway Stent for Long-term Outcome in Patients With Malignant Central Airway Stenosis or Obstruction.

Although an airway stent is used for malignant central airway stenosis or obstruction, long-term outcomes are unknown. In this study, we retrospectively analyzed the clinical features of patients who required stenting for malignant central airway stenosis or obstruction. We retrospectively analyzed clinical data from 116 patients with stenting for central airway stenosis or obstruction who underwent treatment at Toho University Hospital from 1998 to 2018. We evaluated the clinical features, prognoses, and complications for stenting in these patients. The distribution of the 116 patients was as follows: lung cancer, 53; esophageal cancer, 40; thyroid cancer, 8; and others, 15. Patients with thyroid cancer had a significantly higher rate of complications after stenting than patients with lung cancer (P=0.0062), esophageal cancer (P=0.0029), and others (P=0.0062). Patients with esophageal cancer had a significantly worse prognosis than patients with lung and thyroid cancer. In patients with lung cancer the prognosis was significantly different between patients who underwent additional treatment for lung cancer after stenting and patients with no treatment (P=0.0398), and patients who received chemoradiotherapy for lung cancer after stenting had a significantly better prognosis than patients with no treatment (P=0.0306). Stenting for airway stenosis/obstruction may improve prognosis in patients with lung or thyroid cancer, especially if patients with lung cancer undergo additional treatments after stenting, although airway stenting for patients with esophageal cancer was palliative. New treatment strategies may be necessary for patients with esophageal cancer after stenting to improve prognosis.

PercuTwist tracheostomy in an intubated patient with tracheal stent.

The optimal placement of a tracheal tube following percutaneous dilator tracheostomy is technically demanding in patients with tracheal stents. We report a successful technique of tracheostomy tube placement with PercuTwist in an intubated patient with a tracheal stent for malignant stenosis. The endotracheal tube was replaced with a laryngeal mask, a 9.0-mm tracheostomy tube was inserted into the trachea over a PercuTwist percutaneous dilator and through the tracheal stent under video-bronchoscopic vision. The PercuTwist technique kept the lumen of trachea, a laryngeal mask enabled adequate ventilation, and a video-bronchoscope guided the prompt insertion of the tracheostomy tube through the stent.

A Phase II Study of Biodegradable Stents Plus Palliative Radiotherapy in Oesophageal Cancer

AimsSelf-expanding metal stents provide rapid improvement of dysphagia in oesophageal cancer but are associated with complications. The aim of the present study was to test the effectiveness of an alternative treatment of combining biodegradable stents with radiotherapy. Materials and methodsA Simon two-stage single-arm prospective phase II trial design was used to determine the efficacy of biodegradable stents plus radiotherapy in patients with dysphagia caused by oesophagus cancer who were unsuitable for radical treatment. Fourteen patients were recruited and data from 12 were included in the final analyses. ResultsFive of 12 patients met the primary end point: one stent-related patient death; four further interventions for dysphagia within 16 weeks of stenting (41.7%, 95% confidence interval 15.2–72.3%). The median time to a 10-point deterioration of quality of life was 2.7 weeks. Nine patients died within 52 weeks of registration. The median time to death from any cause was 15.0 weeks (95% confidence interval 9.6–not reached). ConclusionThe high re-intervention observed, which met the pre-defined early stopping criteria, meant that the suggested alternative treatment was not sufficiently effective to be considered for a larger scale trial design. Further work is needed to define the place of biodegradable stents in the management of malignant oesophageal strictures.

Diagnostic Accuracy of Magnetic Resonance Cholangiopancreatography to Detect Benign and Malignant Biliary Strictures.

Background:Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive method to detect pancreaticobiliary strictures. In this study, we aimed to evaluate the diagnostic performance of MRCP and detect sensitive and specific radiologic features in distinguishing malignant and benign pathologies.Materials and Methods:In this study, 50 patients with biliary obstruction and a confirmed diagnosis using histopathology were included. The pathologies were evaluated using MRCP which were categorized into malignant and benign strictures. The etiology of strictures was detected using histopathology and endoscopic retrograde cholangiopancreatography. The diagnostic performance of MRCP was calculated using SPSS software. P < 0.05 was considered statistically significant.Results:Of 50 patients, 23 patients (46%) had malignant strictures based on MRCP and histopathology. The sensitivity and specificity of MRCP to detect malignancy were 95.7% and 96.3%, respectively. The most sensitive MRCP features to detect malignancy were upstream biliary duct dilation, abrupt tapering, and the presence of a solid mass with sensitivity 100%, 95.7%, and 78.2%, respectively. The malignancy rate was significantly higher in the strictures with length >11.5 mm or wall thickness >2.75 mm (P < 0.05).Conclusion:MRCP is a sensitive method to differentiate malignant lesions from benign pathologies. A long and thick stricture with the presence of a solid mass, upstream biliary duct dilation, and abrupt tapering is highly suggestive of malignancy.

Feasibility of EUS-guided hepaticogastrostomy for inoperable malignant hilar biliary strictures.

Background and Objectives: EUS-guided biliary drainage (EUS-BD) has emerged as a complementary technique for primary drainage or as a rescue technique after failed endoscopic retrograde cholangiography. The objective of this study was to demonstrate the feasibility of EUS-BD for malignant hilar stenosis (MHS), both as an initial and rescue procedure.Patients and Methods: This study was a retrospective work based on a prospective registry of patients with malignant drainage stenosis of the hilum. For this analysis, only patients who underwent EUS-BD drainage were included. The drainage procedure could be performed by EUS-BD alone or in combination with another technique, for initial drainage or reintervention.Results: Between January 2015 and September 2018, 20 patients were included. The mean patient age was 68 years. Seven patients had primary liver tumors and 13 had obstructions caused by metastasis. Four patients had Type II stenosis, 7 had Type IIIA, 2 had Type IIIb, and 7 had Type IV stenosis. Sixteen patients underwent EUS-guided hepaticogastrostomy (EUS-HGS) for initial drainage and four as reintervention. For initial drainage, 2 patients underwent EUS-HGS alone and 14 underwent EUS-HGS in combination with another technique: 11 combined with endoscopic retrograde cholangiopancreatography (ERCP), 2 with percutaneous transhepatic drainage, and 1 with ERCP and percutaneous transhepatic drainage. The technical success rate for EUS-HGS in the drainage of MHS was 100%, and the clinical success rate was 95%. The mean percentage of liver drained was 84%, with an average 1.7 endoscopic sessions and an average 2.7 protheses. The early complication rate was 35% and the mortality rate was 5%. Five EUS-HGS/ERCP combination drainage procedures were performed in one session and six were performed in two sessions with similar complication rates and percentages of liver segments drained.Conclusion: EUS-BD is a feasible and safe technique for initial drainage and for reintervention procedures. The EUS-HGS/ERCP combination seemed to be useful in cases of complex stenosis and could be performed during the same session or in two sessions.

Endoscopic retrograde cholangiopancreatography and carbohydrate antigen 19-9 in the differential diagnosis of biliary strictures.

bile-duct strictures include a wide spectrum of benign and malignant diseases. to determine the usefulness of endoscopic retrograde cholangio-pancreatography (ERCP) and circulating carbohydrate antigen 19-9 (CA 19-9) for the differential diagnosis of biliary strictures. an observational, prospective, cross-sectional study was performed in 75 patients with biliary stricture diagnosed by ERCP between October 2018 and January 2020. The variables included type of biliary stricture as diagnosed by ERCP, biliary cytology, and CA 19-9 levels. For the statistical analysis, descriptive statistics were used according to type of variable. The relationships between them was analyzed using Pearson's chi-square and Fisher's exact probability tests, assuming differences were significant when p < 0.05. The cut-off point for CA 19-9 was calculated using the ROC curve, and Cohen's kappa index was used to measure concordance between diagnostic methods. cytology was positive in 51 (68 %) patients with biliary stenosis. Mean age was 63 years. Acute cholangitis predominated in malignant strictures (93.7 %). There was agreement between cytology and the cut-off value calculated for CA 19-9 of 85.4 U/mL, with a kappa agreement index of 0.332 (p = 0.004), and between ERCP and cytology, with a kappa concordance index of 0.701 (p < 0.001). a serum CA 19-9 value higher than 85.4 U/mL is highly related to neoplastic biliary stenosis.

A case series of acute intestinal obstruction due to jejunal adenocarcinoma

Background: Though tuberculosis strictures are the most common cause of acute intestinal obstruction, in rare patients, malignant strictures are found in the jejunum causing acute intestinal obstruction and biopsy of these strictures came out to be jejunal adenocarcinoma. Case Presentation: In this case series, we presented three cases of jejunal adenocarcinoma who presented in the emergency department with sign and symptoms of acute intestinal obstruction and peritonitis. All were operated and samples were sent for histopathology which shows jejunal adenocarcinoma in all three cases. Patients were sent to oncology department for adjuvant radiotherapy. Fortunately, all patients responded well to radiotherapy and post op follow up was satisfactory. Conclusion: Although a rare entity, the operating surgeon should keep a high suspicion for malignancy in cases of acute intestinal obstruction if strictures are found in jejunum and cancer directed surgery technique should be followed because this timely treatment is the best survival offer for the patient in otherwise aggressive disease.

EUS-guided gastroenterostomy in a COVID-19-infected patient with duodenal stenosing lymphoma (with videos).

EUS-guided gastroenterostomy (GE) was alternative treatment with respect to conventional therapies for oncological gastric outlet obstruction (GOO) during the COVID-19 pandemic in Italy. This is the case of a patient with obstructing duodenal diffuse large B-cell lymphoma (DLBCL) causing GOO. Malignant duodenal stenosis was treated by the wireless EUS-GE simplified technique: in a single step, EUS-GE was performed, directly puncturing with a hot-cautery device the jejunal loop and using a fully-covered lumen-apposing metal stent (LAMS). A pneumatic stent dilation was finally performed to consolidate the newly-created fistula. The patient was able to tolerate oral feeding and discharged 2 days after. An adequate nutritional state persists after 8 months, with patency of the stent. In the context of the COVID-19 crisis in Italy, EUS-GE was preferred to surgery for GOO with a rapid hospital discharge and prompt oncological treatment resumption. COVID-19 outbreak dramatically changed patients' management in Italy, especially for oncological patients, due to their higher risk of becoming critically ill contracting the virus. Oncologists have to reassess the surgical procedures need, considering nonsurgical management whenever possible.[1] In this period, a 53-year-old male presented with GOO. Upper-GI endoscopy revealed a large duodenal bulb Forrest 3 ulcer [Figure 1], with second duodenum stenosis [Figure 2], positive for DLBCL. Two cycles of specific chemotherapy were given. Finished second cycle, the patient developed a mild form of COVID-19 disease with pharyngeal swabs positive for 90 days. Given GOO presence in COVID-19 patient, EUS-GE was considered. The procedure was performed in a negative-pressure endoscopic room under oro-tracheal intubation. Under endoscopic and fluoroscopic control a guide-wire was advanced through the duodenal stenosis to the first jejunal loop; a 7-French pig-tail nasojejunal tube (N-JT) was advanced through the guidewire and left in situ. A linear echoendoscope (EG38-J10UT-Pentax, Hamburg, Germany) was used and 500 mL of saline was injected into N-JT under continuous EUS-control, to distend the first jejunal loop at Treitz ligament. With adequate loop distension and clear lumen evidence, methylene blue dye was injected through the N-JT for subsequent GE patency assessment. EUS-GE was performed in a single step directly puncturing with a hot-cautery device jejunal loop, positioning a fully-covered LAMS (LAMS; HotAxios-Boston Scientific) 2 cm in caliber, 1 cm length, to connect gastric wall with first jejunal loop [Figure 3].[2] Methylene blue dye outlet was immediately seen; iodinate contrast injection into N-JT confirmed stomach-jejunum connection [Video 1]. Pneumatic stent dilation up to 18 mm was performed [Video 2]. 24 h contrast X-ray confirmed LAMS correct positioning and patency [Figure 4]. Two days after, the patient was able to tolerate oral feeding and was discharged. An adequate nutritional state persists after 8 months, with patency of the stent [Figures 5, 6 and Video 3]. Being the lymphoma in complete remission, a surgical/more definitive strategy will be discussed.Figure 1: Endoscopic aspect of duodenal bulb ulcer, resulted at histology diffuse large B cell-lymphomaFigure 2: Computed tomography-scan view of second duodenum stenosis due to the lymphoma (with naso-gastric tube inserted)Figure 3: Endoscopic view just after second flange positioning of lumen apposing metal stent between the stomach and the first jejunal loopFigure 4: 24-h contrast X-ray after EUS-gastroenterostomy: Lumen apposing metal stent correct positioning and patencyFigure 5: 8-month endoscopic control after EUS-gastroenterostomy: Complete duodenal bulb ulcer regressionFigure 6: 8-month endoscopic control after EUS-gastroenterostomy: Lumen apposing metal stent correct positioning and patencyLumen apposing metal stent correct positioning and patencyGOO increases malnutrition risk and significantly impacts on life quality and oncological regimens adherence. In the context of the COVID-19 crisis in Italy, EUS-GE was preferred to surgery for GOO with a rapid hospital discharge and prompt oncological treatment resumption. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Obstructive Jaundice due to Pancreatic Sarcoidosis

Purpose: Gastrointestinal involvement occurs in 0.1-0.9% of patients with sarcoidosis, being the liver and stomach the most affected organs. Pancreatic sarcoidosis is rare and usually asymptomatic. We herein report a case of a patient with a suspected pancreatic head neoplasia in whom, after performing a pancreaticoduodenectomy, presented a pancreatic sarcoidosis. Method: 61-year-old female with personal history of diabetes and sarcoidosis with lung, skin, and articular involvement. Patient started with obstructive jaundice with no other symptoms. A malignant stenosis of the common bile duct was observed by echoendoscopy and a covered metal stent was inserted using an endoscopic retrograde cholangiographic technique. Histological study after fine needle aspiration were suspected of neoplasia. A CT scan showed no evidence of invasion of surrounding organs, vessels, or lymph nodes. Surgical treatment was proposed due to a suspected pancreatic head neoplasia. Result: A tumor located in the pancreatic head was observed during surgical intervention. No signs of extrapancreatic extension were appreciated. A pancreaticoduodenectomy with inter-aorto-caval and hepatic hilum lymph-node dissection was performed. Subsequent reconstruction con pancreatojejunostomy, hepaticojejunostomy and gastrojejunostomy was made. After surgery, patient presented gastroparesis that required insertion of a nasogastric tube. Histology exam revealed the presence of a non-necrotizing granulomatous inflammatory reaction in the specimen with no tumor. With this findings diagnosis of pancreatic sarcoidosis was made. Conclusion: Pancreatic sarcoidosis may present as a tumor-like mass with obstructive jaundice, weight loss, and abdominal pain as main symptoms. Differential diagnosis of an inflammatory mass from a tumor mass is difficult in theses cases.

Postoperative outcome of tracheal resection in benign and malignant tracheal stenosis.

Tracheal or cricotracheal resection is the standard of care for definitive treatment of tracheal stenosis. However, the incidence is low, the management is complex, and only a few centres have reported their experience. Therefore, more clinical reports on this topic are needed. We performed a retrospective analysis of all patients who underwent tracheal or cricotracheal resection for malignant or benign tracheal stenosis in our institution between 2001 and 2016. Fisher&rsquo;s exact test was used for analysis of complications and recurrence. P-value &lt;0.05 was considered statistically significant. 37 patients, aged 19&ndash;74, underwent tracheal (n = 21, 56.8%) or cricotracheal (n = 16, 43.2%) resection for idiopathic (n = 15, 40.5%), neoplasm-related (n = 11, 29.7%), postintubation/-tracheotomy (n = 10, 27%), and congenital (n = 1, 2.7%) stenosis. Cervical incision was applied in 28 patients (75.7%), and an extended access (5 thoracotomy, 3 hemiclamshell, 1 partial-sternotomy) was required in 9 patients (24.3%). Mediastinal lymphadenectomy was done in 7 patients (18.9%), all with neoplasm-related stenosis. Median resection length was 2.8 cm (range 1.0&ndash;6.0), and longer than 4.0 cm in 6 cases (16.2%). Release manoeuvre was performed in 7 patients (18.9%). All patients were extubated immediately after surgery and median hospital stay was 5 days (range 3&ndash;15). Median follow-up was 6 months (range, 1-93). There was no 30-day mortality, and no dehiscence or fistula occurred at the suture line. Complications were seen in 11 patients (29.7%), significantly correlating to malignant stenosis (p = 0.011) and surgical procedure, meaning extended access (p = 0.011), mediastinal lymphadenectomy (p = 0.016), and release manoeuvres (p = 0.016). Temporary hoarseness was the most common complication (n = 5, 13.5%), but remained persistent in only one patient (n = 1, 2.7%). Recurrence was seen only in patients with idiopathic stenosis (n = 5, 13.5%). Our results confirm good efficacy for surgical resection of tracheal stenosis. The complication rate is relatively low in comparison to the literature, suggesting the importance of managing tracheal stenosis in a tertiary referral centre.

Management and post operative complication of acute intestinal obstruction

Background: Intestinal obstruction remains one of the most common intra-abdominal problems faced by general surgeons in their practice. Its early recognition and aggressive treatment in patients of all ages, including neonates, can prevent irreversible ischemia and transmural necrosis, thereby decreasing mortality and long-term morbidity. Objective of the study was to study the etiological factors, various modes of clinical presentation and management of intestinal obstruction.Methods: Study was conducted by selection of consecutive 50 cases presenting with symptoms and signs suggestive of acute intestinal obstruction from Chigateri General Hospital and Bapuji Hospital attached to J.J.M.Medical College, Davangere during the period from June 2009 to May 2011.Results: In our series, the maximum incidence is in the age group of 41-50 years. The occurrence of acute intestinal obstruction was common in male compared to female. Small bowel obstruction is more common. The commonest presenting symptom was abdominal pain followed by vomiting, distention of abdomen and absolute constipation. Adhesive obstruction (56%) was the commonest cause of acute intestinal obstruction, followed by Obstructed Hernia (18%), Malignancy (6%), Volvulus (4%), Intussusceptions (6%) and TB stricture (6%). Release of adhesions and bands was done in 22 cases. Resection and end-to-end anastomosis was done in 16 cases, which included cases of intussusception, adhesions, stricture, Ileo-caecal growth, colonic growth.Conclusions: Most common etiological factor for intestinal obstruction is postoperative adhesions. Release of adhesions and bands was the most common surgery done.

Palliative surgical treatment of patients, suffering proximal tumoral affection of biliary ducts and the jaundice syndrome

Objective. To compare the efficacy of methods of miniinvasive palliative treatment of malignant hilar strictures with the jaundice syndrome.&#x0D; Materials and methods. Into the investigation 71 patients, suffering proximal obturation jaundice of tumoral genesis, were included. The patients were divided into three Groups: Group I - 26 patients, to whom external-internal suprapapillary cholangiostomy was done; Group II - 28 patients, in whom transcutaneous transhepatic antegrade endobiliary stenting was performed; Group III -17 patients, to whom endoscopic retrograde biliary stenting was accomplished.&#x0D; Results. Technical success in all the Groups have constituted 100%; clinical one - in 94.0%: in Group I - 96.2%, in Group II - 89.3%, and in group III - 82.4% (p&gt;0.05). In Group I general rate of morbidity was lesser, including cholangitis and pancreatitis. The duration of cholangitis was lesser as well. Cumulative survival were the highest in Group of patients, to whom external-internal suprapapillary cholangiostomy was performed (135 days at average), while the least one - in Group of the patients, in whom endoscopic retrograde biliary stenting was done (90,6 days). In Group of patients, to whom transcutaneous transhepatic antegrade endobiliary stenting was performed, this index have constitited 101.2 days.&#x0D; Conclusion. In proximal strictures of biliary ducts of tumoral genesis on background of jaundice the priority method of palliative treatment must be external-internal suprapapillary cholangiostomy, while the second-line of surgical treatment must constitute transcutaneous transhepatic antegrade endobiliary stenting. Endoscopic retrograde biliary stenting owes the lowest priority.

Superiority of Self-Expandable Metallic Stents Over Plastic Stents in Treatment of Malignant Distal Biliary Strictures

Treatment of malignant biliary strictures with endoscopic retrograde cholangiopancreatography (ERCP) guided stent placement is highly effective. Our objective was to compare the efficacy and adverse outcomes between plastic stents (PS) and self-expandable metallic stents (SEMS). A cohort study was performed of all consecutive patients who underwent ERCP with stent placement for the management of malignant biliary stricture. Comparisons on clinical success, patency duration, stent dysfunction, unplanned reintervention and adverse outcomes were performed. Univariate and multivariable analyses were performed to identify factors associated with clinical success, need for reintervention, and stent dysfunction. From 2012 to 2019, 1139 patients underwent ERCP with PS placement while 1008 patients received SEMS for the management of malignant biliary stricture. In distal strictures, SEMS reported a significantly higher rate of clinical success compared with PS (94.1% vs 87.4%, P < 0.001) and a lower rate of unplanned reintervention (17.1% vs 27.4%, P < 0.001). In hilar strictures, the rates of clinical success and unplanned intervention were comparable. The patency duration and time to unplanned reintervention were significantly longer with SEMS than PS, irrespective of stricture location. In distal stricture, PS was associated with a significantly higher rate of cholangitis than SEMS (6.9% vs 2.4%; P < .001) but a lower rate of pancreatitis (3.6% vs 6%; P= 0.021). Given superior efficacy, durability and lower rates of cholangitis, SEMS should be offered as the first line endoscopic treatment option for malignant distal biliary stricture. For malignant hilar stricture, SEMS is an attractive alternative to PS in some cases by offering a comparable efficacy with a superior durability.

Clinical Evaluation of a Newly Developed Guidewire for Pancreatobiliary Endoscopy.

Background: The guidewire (GW) plays an important role in pancreatobiliary endoscopy. GW quality is a critical factor in the effectiveness and efficiency of pancreatobiliary endoscopy. In this study, we evaluate a new 0.025 inch multipurpose endoscopic GW: the M-Through. Methods: Our study was a multicenter retrospective analysis. We enrolled patients who underwent endoscopic procedures using the M-Through between May 2018 and April 2020. Patients receiving the following endoscopic treatments were enrolled: common bile duct (CBD) stone extraction, endoscopic drainage for distal and hilar malignant biliary obstruction (MBO), and endoscopic drainage for acute cholecystitis. For each procedure, we examined the rate of success without GW exchange. Results: A total of 170 patients (80 with CBD stones, 60 with MBO, and 30 with cholecystitis) were enrolled. The rate of completion without GW exchange was 100% for CBD stone extraction, 83.3% for endoscopic drainage for MBO, and 43.3% for endoscopic drainage for cholecystitis. In unsuccessful cholecystitis cases with the original GW manipulator, 1 of 8 cases succeeded in the manipulator exchange. Including 6 cases who changed GW after the manipulator exchange, 11 of 16 cases succeeded in changing GW. There was significant difference in the success rate between the manipulator exchange and GW exchange (p = 0.03). The insertion of devices and stent placement after biliary cannulation (regardless of type) were almost completed with M-through. We observed no intraoperative GW-related adverse events such as perforation and bleeding due to manipulation. Conclusion: The 0.025 inch M-Through can be used for endoscopic retrograde cholangiopancreatography-related procedures efficiently and safely. Our study found high rates of success without GW exchange in all procedures except for endoscopic drainage for cholecystitis. This GW is considered (1) excellent for supportability of device insertion to remove CBD stones; (2) good for seeking the biliary malignant stricture but sometimes need the help of a hydrophilic GW; (3) suboptimal for gallbladder drainage that require a high level of seeking ability.

Palliation in Malignant Esophageal Stricture and Fistulas with Self-expandable Metallic Stents

Palliation in Malignant Esophageal Stricture and Fistulas with Self-expandable Metallic Stents

MR CHOLANGIO-PANCREATICOGRAPHY AS A TOOL FOR EVALUATION OF PATIENTS WITH PANCREATICOBILIARY DISEASES

Objectives Of Study: 1. To describe features of pancreaticobiliary diseases on MRCP. 2. Outlining the extent in terms of involvement of adjacent structures, vessels
and soft tissues. 
 3. To help in deciding further course of management. 4. To identify the anatomical variants. 
 5. To prove the Magnetic Resonance Cholangio-Pancreatography (MRCP) is
one of the best imaging modality for evaluation of pancreatico-biliary disease. Material And Methods:The present study was undertaken to evaluate the role of MRCP in evaluation of pancreaticobiliary diseases. The study will be done on patients presenting with features suggestive of pancreatico-biliary diseases attending the OPD or admitted in various wards of Krishna Rajendra hospital, Mysore attached to Mysore Medical College &amp; Research Institute, Mysore. A total of 30 patients were included in our study. Result:Majority of patients in study population were males (60%) while 40% were females. The mean age of the study sample was 37.5 years and maximum numbers of cases were observed in age group of &gt; 40 years. Majority of pathologies observed were benign 18(60%). Pancreatitis was the most common finding (33.3%) followed by Cholangiocarcinoma (20%), Choledocholithiasis (13.4%), Periampullary carcinoma (10%), Ca. Pancreas (6.7%) &amp; Choledochal cyst (6.7%).Pancreatitis is common in males followed by Cholangiocarcinoma, which is common in both males &amp; females.Both benign &amp; malignant strictures have equal predominance. Both benign &amp; malignant strictures are common in proximal CBD. Conclusion: MRCP is non-invasive, non-ionizing imaging method for evaluation of pancreatico-biliary anatomy and pathology. It is superior diagnostic modality in detection and characterization of pancreatico-biliary pathologies.